Organ-specific autoimmune diseases
Gabriel Virella in Medical Immunology, 2019
Graves’ disease, also known as thyrotoxicosis, diffuse toxic goiter, and exophthalmic goiter, is the result of the production of antibodies against the thyroid-stimulating hormone receptor (TSHR), usually of the IgG1 isotype. Three functional types of TSHR antibodies can be detected in patients with Graves’ disease. In 80%–90% of the patients with Graves’ disease, the antibodies stimulate the production of thyroid hormones by activating the adenylate cyclase system after binding to the TSH receptor the activity of the thyroid gland. For that reason they have been known by a variety of descriptive terms, including long-acting thyroid stimulator (LATS). A second type of TSHR antibodies induces apoptosis of the cells expressing it, contributing to the development of thyroid inflammation. Finally, a third type of TSHR antibodies blocks the receptor and does not stimulate the production of thyroid hormones. These antibodies are detected in about 4% of patients with Graves’ disease, and when their activity predominates (in about 50% of the cases in which they are detected), cause hypothyroidism, while the remaining patients may be euthyroid or hyperthyroid depending on the ratio of blocking versus stimulating antibodies. These blocking antibodies can also be detected in about 10% of patients with Hashimoto's thyroiditis.
The laboratory and imaging approaches to thyroid disorders
David S. Cooper, Jennifer A. Sipos in Medical Management of Thyroid Disease, 2018
The measurement of thyroid autoantibodies is of value in selected clinical situations. The presence of thyroid-stimulating immunoglobulins in patients in whom the etiology of hyperthyroidism is uncertain can lead to a diagnosis of Graves’ disease. Current third generation TRAb assays have a 95% sensitivity and specificity for diagnosing Graves’ disease (105). Assessment of anti-TSH receptor antibody levels before treatment can be predictors of the likelihood of remission after a course of antithyroid drug therapy or the development of Graves’ ophthalmopathy (106). Persistence of high levels of thyroid-stimulating immunoglobulins in Graves’ disease following therapy is associated with increased rates of recurrence (107, 108). When detected during the third trimester of pregnancy in a woman with Graves’ disease, significant increases in either TSH-binding inhibitors or thyroid-stimulating immunoglobulins titers correlate with the development of intrauterine and neonatal hyperthyroidism due to transplacental passage of immunoglobulins (109).
Preoperative workup
J. Richard Smith, Giuseppe Del Priore, Robert L. Coleman, John M. Monaghan in An Atlas of Gynecologic Oncology, 2018
Hyperthyroidism poses perioperative cardiac risk due to the ability of both T4 and triiodothyronine (T3) to impose inotropic and chronotropic effects on cardiac function. The most common cause of hyperthyroidism is Graves’ disease, an autoimmune disorder resulting in increased thyroid hormone production. Hyperthyroidism is characterized by tachycardia, atrial fibrillation, fever, tremor, goiter, and ophthalmopathy. The greatest perioperative risk to an untreated hyperthyroid patient is the development of thyroid storm and should be considered in any patient suffering postoperative fever, tachycardia, hyperpyrexia, nausea and vomiting, or delirium. Treatment includes beta-blockade, thionamides, iodine, and corticosteroids in addition to admittance to an intensive care unit for appropriate monitoring. Until control is achieved, moderate to severe hyperthyroidism necessitates surgery cancellation.
Serum thyroid stimulating hormone level for predicting utility of thyroid uptake and scan
Published in Endocrine Research, 2021
Lauren Buehler, Alireza Movahed, Keren Zhou, M. Cecilia Lansang
A total of 137 patients were eligible for inclusion in the study. The median TSH value for the study population was 0.008 µU/mL with an interquartile range (IQR) of 0.005, 0.011 µU/mL (reference range 0.4 to 5.5 µU/mL). The median free T4 value was 1.7 µU/mL (IQR 1.3, 2.8, ref range 0.9–1.7 ng/dL), and the median free T3 value was 4.95 µU/mL (IQR 3.7, 8.7 µU/mL, ref range 2.3 to 4.1 pg/mL). The majority of subjects were female (75%, n = 103), and the mean age at the time of TUS was 50 ± 23 years (SD). Antibodies associated with thyroid disease, including thyroid binding immunoglobulin (TBI), thyroid stimulating immunoglobulin (TSI), anti-microsomal, and anti-thyroglobulin antibodies were tested in 120 (87%) of our patients. Of those tested, 68 patients were positive for TSI, 60 were positive for TBI, 35 were positive for anti-microsomal, and 22 were positive for anti-thyroglobulin antibodies (Table 1, 2). There were two time points for which the scans were read, either around 4 hours (median 4.0 h) or around 24 hours (median 24.1 h). At the 4 h time mark, the median uptake percentage was 34% (IQR 13, 52%), and at the 24 h time mark, the median percentage was 13% (IQR 8, 34%).
Recurrent thyrotoxicosis following near-total thyroidectomy
Published in Baylor University Medical Center Proceedings, 2020
Paul Gaschen, Joehassin Cordero, Alan N. Peiris
Graves’ disease, an immune-mediated disorder associated with elevated thyroid-stimulating immunoglobulins (TSIs), is a common cause of hyperthyroidism. Hyperthyroidism is usually treated with medication, radioactive iodine, or surgery. Recent evidence indicates that radioactive iodine treatment may increase the risk of solid tumors1 and exacerbate Graves’ ophthalmopathy. Thyroidectomy may also be considered an accepted therapy during the second trimester of pregnancy.2 Additionally, there has been a preference for total thyroidectomy in the treatment of hyperthyroidism. Total thyroidectomy produces better outcomes than subtotal thyroidectomy because of the reduced rate of recurrent thyrotoxicosis.3 As such, total thyroidectomy has been assumed to be curative in hyperthyroidism. In this article, we present the rare case of recurrent thyrotoxicosis following near-total thyroidectomy.
Squamous cell carcinoma of the lung: improving the detection and management of immune-related adverse events
Published in Expert Review of Anticancer Therapy, 2022
Lara Kujtan, Rama Krishna Kancha, Beth Gustafson, Lindsey Douglass, Christopher RH Ward, Blake Buzard, Janakiraman Subramanian
Either autoimmune thyroid disease may manifest as primary hypothyroidism secondary to destructive thyroiditis or hyperthyroidism associated with Graves’ disease [47]. Routine thyroid function monitoring every 4–6 weeks is recommended since patients are often asymptomatic [38]. Hypothyroidism is the more common toxicity, albeit generally mild, and not necessitating ICI cessation. For patients with TSH >10mIU/L, levothyroxine replacement at 1.6 mcg/kg IBW is recommended, with continuation of ICI. Hyperthyroidism occurs less frequently and may rarely lead to Graves’ disease [41]. Hyperthyroidism may be transient and evolve into hypothyroidism due to thyrotoxicosis. For symptomatic thyrotoxicosis, endocrinology should be consulted for potential beta-blocker use [37,39]. ICIs are generally continued during thyrotoxicosis treatment.
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